The Reply to the letter on the cost-effectiveness of human papillomavirus in Punjab further distorts the scientific record

The Reply to the Letter on the
Cost-Effectiveness of Human
Papillomavirus in Punjab Further
Distorts the Scientific Record
Articles in peer-reviewed scientific journals become part
of the scientific record. For this reason, the correspondence
column opens up the science to wider peer review as
part of the effort to uphold the scientific validity of published
science. We are concerned that the reply about the
cost-effectiveness of human papillomavirus vaccination in
Punjab1 is not entirely factual, and it also misrepresents
the science published by others.
Prinja et al1 quote Goldie et al2 as reporting the following:
“Only if the price of vaccine is considered as high
as US $100 per dose, the cost per DALY [disabilityadjusted
life-year] averted generally exceeds the costeffectiveness
threshold of the respective countries.”
This is not true. Goldie et al2 evaluated health and
economic outcomes of human papillomavirus vaccination
in Global Alliance for Vaccines and Immunization–eligible
countries, and they found that at a cost per dose of
approximately US $2, the cost per DALY averted was less
than I $100 for 49 of 72 countries and less than I $200 for
80% of the countries. They wrote that “at higher costs,
including the current price in the US (more than US $100
per dose) the cost per DALY averted generally exceeds
cost-effectiveness thresholds that would be considered
favorable, implying the resources would save more lives if
allocated elsewhere.”
By the deletion of the phrase “at higher costs” (in
comparison with US $2 as suggested by the previous sentence)
and the incorrect insertion of the word “only”
(“only if the price of vaccine is considered as high as US
$100 per dose”), the inference has been changed
substantially.
In our letter,3 we point out that the costeffectiveness
calculation of Prinja et al4 assumes 99.1%
mortality for cervical cancer (733 deaths among 740 cases
of cervical cancer). The authors in their reply suggest that
this is because 51.6% of the cases in India are detected
only at stage 3 or 4 when the prognosis is not good. If we
assume 100% mortality in this group with a “poor
prognosis” and that all 7 survivors were among the 48.4%
(358 patients) detected at stage 1 or 2, the mortality in the
group with a “good prognosis” (stage 1 or 2 cervical cancer)
works out to be 98%. This mortality rate is unprecedented
in the literature for this cancer. Obviously, either
the input data or the model itself is defective if the results
thrown up are so obviously erroneous.
We are, therefore, concerned that the authors reiterate
that their “findings of cost-effectiveness are valid and
should be used for policy in India.” The evidence-based
deliberations of the National Technical Advisory Group
on Immunization in India sets great store by published
literature, and it is crucial that distortions in costeffectiveness
analyses from India be corrected.
FUNDING SUPPORT
No specific funding was disclosed.
CONFLICT OF INTEREST DISCLOSURES
Jacob M. Puliyel is a member of the National Technical Advisory
Group on Immunization of the Government of India. The opinions
expressed are personal.
REFERENCES
1. Prinja S, Bahuguna P, Faujdar DS, et al. Reply to cost-effectiveness
calculations of human papillomavirus vaccination in Punjab may be
flawed. Cancer. doi:10.1002/cncr.31075 [epub ahead of print].
2. Goldie SJ, O’Shea M, Campos NG, Diaz M, Sweet S, Kim SY.
Health and economic outcomes of HPV 16,18 vaccination in 72
GAVI-eligible countries. Vaccine. 2008;26:4080-4093.
3. Suman V, Puliyel JM. Cost-effectiveness calculations of human papillomavirus
vaccination in Punjab may be flawed. Cancer. doi:10.1002/
cncr.31074 [epub ahead of print].
4. Prinja S, Bahuguna P, Faujdar DS, et al. Cost-effectiveness of human
papillomavirus vaccination for adolescent girls in Punjab state: implications
for India’s universal immunization program. Cancer. 2017;
123:3253-3260.
Vivian Suman, DCH
Jacob M. Puliyel, MD, MRCP, MPhil
Department of Pediatrics
St. Stephens Hospital
Delhi, India
DOI: 10.1002/cncr.31167, Published online Month 00, 2017
in Wiley Online Library (wileyonlinelibrary.com)
Cancer

This personal archive site is maintained by Jacob M Puliyel. The copyrights of the content here lies either with the author or the publisher, and its use here in this personal archive is considered fair use.